Status Asthmaticus (Case 45)

Chapter 87 Status Asthmaticus (Case 45)



Venkat R. Shankar, MD, MBA




Case


A 6-year-old child known to have asthma has been having increasing difficulty breathing for the past 24 hours. He developed a cold and a runny nose 2 days ago, and has been taking repeated “breathing treatments” overnight without any relief. Since this morning, he has been unable to speak in sentences and cannot walk to the bathroom.




Differential Diagnosis









Asthma Congestive heart failure Pneumonia


Speaking Intelligently


Status refers to a condition that persists despite appropriate therapy. Children in status asthmaticus typically appear very ill and distressed. The most critical aspect of management is to assess the degree of oxygenation using pulse oximetry and to provide supplemental oxygen. I also assess mental status as a marker of ventilation—the degree to which they are responsive. Lack of adequate responsiveness is often the harbinger of respiratory arrest. One of the first priorities is to administer inhaled beta-agonists in addition to supplemental oxygen. Establishing vascular access and administering intravenous methylprednisolone early are also key. I usually do not obtain an arterial blood gas determination—as the decision to assist with mechanical ventilation is usually evident based on clinical examination.



Patient Care



Clinical Thinking



• Can I reverse the process with aggressive bronchodilators and anti-inflammatory therapy (i.e., corticosteroids)?

• Is the child dehydrated from poor oral intake and insensible fluid losses due to hyperpnea?

• Hypoxemia can be life threatening; however, one can withstand a significant degree of hypercapnia.


History



• Previous history of wheezing, “bronchitis,” and seasonal cough is suggestive of asthma.

• Nocturnal or exercise-induced cough may also be suggestive of asthma.

• Fever may be present, although a high degree of fever could indicate pneumonia.

• Exposure to tobacco, animals, pollen, or other allergens may suggest an asthma trigger.

• A history of sudden choking may suggest foreign body aspiration, not asthma.

• Symptoms of poor feeding or growth or easy fatigue may suggest a cardiac etiology.


Physical Examination



• Vital signs: The child is tachypneic with increased work of breathing with intercostal, subcostal, and supraclavicular retractions. Tachycardia and bounding pulses are common. Decreased oxygen saturation on room air pulse oximeter may be present.

• Pulsus paradoxus, an exaggerated decrease in systolic blood pressure on inspiration (greater than 10 mm Hg), is suggestive of severe disease.

• In general, the child may appear distressed. The inability to speak in short sentences is a sign of severe status asthmaticus.

• On lung examination, air entry may be severely diminished, and wheezing may not be audible in severe cases. Prolonged expiratory phase is typical.

• A heart murmur or gallop and hepatomegaly may suggest congestive heart failure as an etiology rather than asthma.

• Evaluation of mental status is helpful in deciding the severity of asthma and need for assisted ventilation.


Tests for Consideration



• Electrolytes: To assess degree of dehydration and presence of acidosis. $115

• Arterial blood gas (ABG) levels: May help in cases that are borderline for intubation $45

• Complete blood count (CBC): May help differentiate an infectious process from asthma, or asthma with secondary pneumonia $110
< div class='tao-gold-member'>

Related posts:

  1. The Special Needs Child
  2. Diarrhea (Case 6)
  3. Pediatric Poisonings (Case 54)
  4. Note Writing

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Status Asthmaticus (Case 45)

Full access? Get Clinical Tree
Get Clinical Tree app for offline access